MEDICAL RELEASE I hereby give my permission of any and all medical attention necessary to be administered to my child (NAME) __________________________ in the event of an accident, injury, sickness, etc., under the direction of the person(s) listed below, until such time as I may be contacted. This release is effective for a period of one (1) year from the date given below. I also hereby assume the responsibility for payment of any such treatment. MY ADDRESS IS _________________________________________________________________________ HOME PHONE (____)_______________WORK (_____)________________ CELL (____) ______________ MY INSURANCE COMPANY IS _____________________________________________________________ MY POLICY NUMBER IS ___________________________________________________________________ In case I cannot be reached, any of the following is designated to act in my behalf. 1. Coach (Name)______________________________________________________ 2. Assistant Coach (Name) ______________________________________________ 3. Assistant Coach (Name) ______________________________________________ 4. A League Representative where my child is playing 5. Any Tournament representative where my child is participating in a tournament. OUR PHYSICIAN IS _______________________________________________________________________ PHYSICIAN ADDRESS _____________________________________________________________________ KNOWN ALLERGIES ______________________________________________________________________ SIGNATURE (PARENT/GUARDIAN)_________________________________________________________ SUBSCRIBED AND SWORN TO BEFORE ME, THIS ______ DAY OF ___________, 20 _____ NOTARY SIGNATURE Seal